Issue 7

Is High Tissue Transglutaminase Antibody Titers Enough to Diagnose Celiac Disease in Children?

Zuhair M. Al-Musawi

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 860-866

Background. The current standard method for diagnosis of celiac disease (CD) is an adequate small-bowel biopsy (usually obtained through upper gastrointestinal tract endoscopy) showing characteristic histopathological changes, followed by a therapeutic response to a gluten free diet. Commercially available IgA tissue trassglutaminase antibody (TTG) screening tests have been developed with variable sensitivities and specificities. The use of high titer cutoff values than currently recommended should improve the specificity of the test and its positive predictive value.Objectives. To evaluate the significance of high TTG titers in the diagnosis of CD.Methods. One hundred sixteen patients with signs and symptoms suggestive of CD had undergone TTG testings (IgA &IgG class) and small-bowel biopsies while 50 healthy volunteers without family history of CD, were sent for TTG testings only. Ten patients excluded from the study because their TTG values and small-bowel biopsies were negative. Results. Ninety eight of 106 zpatients demonstrated positive biopsy results. Seventy two of 106 patients had IgA TTG levels of >100U/ml, with 70 of 72 exhibiting positive biopsy Results. Twenty two of 28 patients with IgA TTG values >18-100U/ml exhibited positive biopsy results. Six patients with negative IgA TTG levels of ≤18 U/ml had positive biopsies and positive IgG TTG levels (>18 U/ml).Two volunteers had positive IgA TTG levels (>18U/ml).The sensitivity and specificity of IgA TTG were 94.3% and 96% respectively while the sensitivity of duodenal biopsy was 92.6%(8 symptomatic patients had negative small-bowel biopsy while their IgA TTG values were positive).Conclusions. Symptomatic patients with high titer TTG levels >100 U/ml can be treated as CD without small-bowel biopsy and a negative biopsy does not exclude CD.Key words. Celiac Disease; Tissue Transglutaminase Antibody; Small-Bowel Biopsy.Abbreviations. CD, Celiac Disease; TTG, Tissue Transglutaminase Antibody.

Molecular Basis of G6PD Deficiency in Hyperbilirubinemic Neonates in Middle Euphrates Province : Iraq

William M. Frankool; Fadhil Jawad Al-Tu

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 867-881

Background: Neonates G6PD deficiency screening has been recognized as an essential component of public health care in most developed and some Mediterranean countries. However, such screening is yet to be widely embraced in Iraq. More than 442 variants of G6PD have been identified by various molecular methods. The aim of the present study was to determine the normal values of G6PD and deficiency prevalence of this enzyme in male neonates and then determination of the type molecular variant of G6PD prevalence in Middle Euphrates Province of Iraq. Objective: The objective of this study was to investigate the molecular basis of glucose-6-phosphate dehydrogenase (G6PD) deficiency in hyperbilirubinemic neonates in Middle Euphrates province of Iraq. Molecular methods (genomic DNA extraction, polymerase chain reaction and restriction fragment length polymorphism analysis) and then investigate the type of G6PD variant predominantly present have been performed. Methods: The study included a total of 917 full-term male neonates which were divided into two groups: The first group which include 704 neonates (76.8%) associated with severe hyperbilirubinemia were admitted in Middle Euphrates Province Teaching Hospitals of Maternity and Pediatrics during 1st Oct., 2007 to 12th July, 2008 with age ranged between 1 – 28 days, their total serum protein , TSB levels ≥ 15 mg/dl. The second group which include 213 neonates (23.2%) with the same age ranged were used as control group, their TSB levels ˂ 1 mg/dl. The blood sample taken from each neonate was divided into two aliquots: the first aliquot was used for the determination of total and serum conjugated bilirubin (TSB and SCB), and G6PD activity. The second aliquot was used for molecular analyses including genomic DNA extraction and then application of polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) protocols. Results and Discussion: Severe hyperbilirubinemic neonates were screened for erythrocyte G6PD enzyme activity, severe G6PD deficiency was detected in 75 of 704 hyperbilirubinemic neonates included and their activity levels was significantly decreased (P < 0.05) to less than 10% of that found in control group. Therefore, the incidence of severe G6PD deficiency identified in Middle Euphrates Province of Iraq was 10.65%. TSB levels were markedly elevated to ( ≥ 15 mg/dl), whereas the mean ± SD values of SCB were significantly lower than that found in controls (P < 0.05) , SCB was undetectable in 32 of 75 (42.67%) of hyperbilirubinemic neonates with severe G6PD deficiency which imply a partial defect of bilirubin conjugation. The molecular part of the study involved the extraction of genomic DNA from hyperbilirubinemic neonates with severe G6PD deficiency which was detected by agarose gel electrophoresis and then amplified by PCR and finally was subjected to digestion by endonuclease restriction enzymes to create RFLP and to enable the detection of mutation that caused G6PD deficiency. The majority of affected severe G6PD deficient neonates with hyperbilirubinemia in Middle Euphrates province – Iraq, were due to G6PD Med variant (C563T, Ser 188 Phe) , of such 67 of 75 neonates (89.3%) have this type of mutation, and 5 of 75 (6.67%) have G6PD A- variant (G202A ; A376G mutations), whereas only 3 of 75 (5.3%) remain unknown G6PD variants which require future molecular studies.Conclusion: The predominant G6PD gene detected in hyperbilirubinemic neonate with severe G6PD deficiency in Middle Euphrates province was G6PD Med.variant. Keywords : Hyperbilirubinemia, G6PD gene, Polymerase Chain Reaction , RFLP.

Laryngoscopy in patients undergoing thyroid surgery – is it mandatory or unnecessary routine?

Mohend A. N. Alshalah

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 882-888

Background: The objective of this study was to evaluate the effectiveness of screening laryngoscopic examination in evaluating vocal fold (VF) mobility before and after thyroid surgery. Patients and methods: A prospective study of 112 patients underwent thyroid surgery at the Hilla teaching general Hospital and Al-Shafaa private hospital were undertaken in order to study the patterns of pre-operative and postoperative voice changes and Indirect laryngoscope (IDL) findings. Patients with pathologic findings at postoperative laryngoscopy underwent reassessment of voice and (VF) mobility for 6 months duration.Results: A total of (9.8 %) of patients had pre-operative suspicion of VF Palsy, only (27.3 %) of this group had abnormalities detected on pre-operative IDL .Of 101 documented IDL, no vocal cord pathology in asymptomatic patients were detected.Post operativelyConclusions: Preoperative laryngoscopy is necessary in symptomatic patients and those who undergo re operation or in patients when malignancy is suspected. The necessity of a preoperative laryngoscopy in all other patients must be questioned. Postoperative laryngoscopy and additional diagnostic testing better to be reserved for symptomatic patients.

Prevalence of Endocrine Disorders among Iraqi Women with Menstrual Disturbances

Hussein Kadhem Al-Hakeim

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 889-896

background and Objectives: The main causes of menstrual cycle disturbances are
classified as hormonal abnormalities, structural abnormalities, bleeding diatheses,
anovulation, polycystic ovary (PCO), obesity and miscellaneous. In this work, the
prevalence of endocrine disorders in Iraqi women with menstrual disturbances was estimated.
Patients and Methods: One hundred Eighteen females with menstrual disturbances
(delay>10 days occasionally) were included in this study in addition to thirty seven control
women. They were attending to the gynecological clinics for regulation of menstruation
cycle. The study excluded any women taking steroid hormones, neuroleptics, anticoagulants
and cytotoxic agents that frequently lead to menstrual disturbances. Luteinizing hormone
(LH), follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactine,
total testosterone, estradiol (E2) and progesterone were estimated in the second day of the
menstrual cycle using ELISA technique using a ready for use kits.
Results: The endocrine disorders in menstrual disturbances in the Iraqi women under study
were: 16.1% hypothyroidism, 3.4% hyperthyroidism, 3.4% type 1 diabetes mellitus, and
pituitary tumor was observed in 1.6 % of patients. Additionally, there is a high prevalence of
patients with POCS cases and a high significant increase in the mean of BMI in the patients
when compared with the control women.
Conclusion: Surprisingly, the most common endocrine disorder in the women with menstrual
disturbances group was hypothyroidism. Additionally the PCO is common in these women.
The prevalence of endocrine disorders in irregular women in Iraq was lower than the other
countries and the type of prevalent endocrine disorders is different

Morphological Changes of Megakariocytes in Diseases That Cause Thrombocytopenia

Mohammad Shnain Ali

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 897-901

Background:Morphological changes of megakariocytes are common and they are different according to the cause of thrombocytopenia.Aim: To differentiate the morphological changes of megakariocytes according to the cause of thrombocytopenia.Materials and methods: A total number of 88 cases of symptomatic thrombocytopenia (in which bone marrow examination was indicated) were included. The study was done in a legal private laboratory for hematological investigations (Zaid Bin Ali private laboratory) in karbala city. Patients with thrombocytopenia were referred from different specialists. Blood samples were taken for complete blood picture and platelet count. Thrombocytopenia was defined as platelet number below 100 X109/L. Bone marrow aspirate samples were taken, bone marrow smear slides were made, fixed and stained by Leishman stain, dried and examined under the light microscope for various abnormal morphological changes of megakariocytes. Normal megakariocytes were defined as the largest marrow cells which retain lobulated nuclei (4-16 lobes) while abnormal morphological changes include large magakariocytes with dispersed nuclear lobes, dwarf micromegakario- cytes, juvenile megakariocytes, emperipolesis, megakariocytes with bare nuclei, presence of cytoplasmic vacuoles, hyperpolyploidy (defined as nuclear lobes more than 16) and hypopolyploidy (defined as nuclear lobes less than 4). Using Fisher’s exact test, P value of less than 0.05 was considered to be significant.Results: Large magakariocytes with dispersed nuclear lobes, dwarf micromegakariocytes, juvenile megakariocytes and emperipolesis were 31% (9 out of 29), 34.48% (10 out of 29), 96.55% (28 out of 29) and 72.41% (21 out of 29), respectively in cases of thrombocytopenia which are caused by ITP. Large magakariocytes with dispersed nuclear lobes, dwarf micromegakariocytes, juvenile megakariocytes and emperipolesis were 71.42% (5 out of 7), 85.71% (6 out of 7), 57.14% (4 out of 7) and 57.14% (4 out of 7), respectively in cases of thrombocytopenia which are caused by MDS. In MDS, the presence of large magakariocytes with dispersed nuclear lobes and dwarf micromegakariocytes was statistically significant when compared with other diseases that cause thrombocytopenia (P<0.05).The other abnormal morphological changes of megakariocytes in cases of thrombocytopenia are shown in table 1. While the presence of one or more megakaryocytic changes or absence of such changes in various hematological cases of thrombocytopenia are shown in table 2.Conclusion: There are great interactions and similarities in morphological changes of magakariocytes among different hematological diseases; however, the diagnostic approach will vary when detailed knowledge about morphological changes of megakariocytes is available.Key words: dwarf micromegakariocytes, bone marrow smears, thrombocytopenia, myelodysplastic syndrome.

Prevalence of Teeth Loss and Its Relation to The Oral Health Behaviors among Type 2 Diabetic and Non Diabetic Patients

Hawraa Khalid Aziz

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 902-909

Background: Diabetes can affect the health of the teeth and the surrounding structures that are increased the risk of developing periodontal disease that resulting destruction of the bone and the periodontal tissues that lead to greater teeth loss than those without diabetes.Objectives: The aim of this study to compare the teeth loss of the diabetic and non-diabetic patients considering the age, sex , duration of the disease and oral health behaviors.Methods: Teeth loss of 67 adult diabetics and 67 non-diabetic patients of age 45-74 years old were examined also diabetic group was compared according to the duration of the disease. The oral health behavior including the frequency of the tooth brush per day, cleaning method, and tobacco use were compared among the diabetic and non-diabetic groups. Results: There is highest significant difference in mean number of the teeth loss between the diabetics and non diabetics with non significant difference between the patients of more than 10 years and less than 10 years of the duration. The diabetics showed significantly higher frequency of the tooth brush and tobacco use than non-diabetic group and the teeth loss decreased with increased the frequency of the tooth brush. Conclusions: The teeth loss was greater in diabetics than non-diabetics, when the duration of the disease was increased there was increased in teeth loss. The study indicated that diabetic subjects should improve their oral hygiene practices.Keywords: Teeth loss, diabetic patients, oral hygiene.

Schistosomial Infestation and Histopathplogical Features to Patients Diagnosed as Acute Appendicitis

Ali A. Al-Katib; Mohend A. N. Al-Shalah; Ali H. Al-Timimi

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 910-913

background: Schistosomial infestation is commonly infested the appendix. However it
is not known if this- is a predisposing, factor for appendicitis, or a mere coincidental
histological finding.
Patients and methods: In the present study a total of 48 cases (40 males and 8 females)
underwent appendectomy for schistosomal appendicitis over a 10-year period at Basrah and
Hilla Teaching hospitals were studied. Their histological slides were reviewed carefully.
Results: showed that the highest incidence of schistosomal appendicitis was recorded in the
21-40-year age group. Ova were seen in the submucosal layers of all the excised appendices.
The most common tissue responses were submucosal fibrosis (93.8%) and eosinophilia
(89.6%), followed by the presence of suppurative inflammation (75%). Granulomatous
reaction was evident in 32 cases (66.6%),and commonly found in the serosa and submucosa.
A feature of atrophy of submucosal lymphoid follicles was noted in 48% of the cases and
hyperplasia in 44%. most.. Similar tissue responses were histologically seen in three normal
appendices examined.
Conclusion: Appendiceal infestation may predispose to appendicitis in the majority of
affected cases, but in others, it may well be a mere coincidental histological finding.
However, preoperative knowledge bears no Clinical significance and does not alter

Uric Acid and Endothelial Dysfunction in Essential Hypertension

Halla G. Al-Gebouri; Zainab Abdul Razak Al- Sharifi

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 914-918

Background: Uric acid (UA) can stimulate the biosynthesis of c-reactive protein (CRP), and that might be one of the mechanisms underlying the endothelial dysfunction. Several studies showed an independent link between UA and CRP suggest that chronic exposure to mild hyperuricemia may be a factor that contributes to micro inflammation and raised CRP in individuals with essential hypertension.Aim: The aim of this study is to investigate the relationship between the serum uric acid, CRP , total cholesterol and endothelial dysfunction in patient with essential hypertension .Patients and methods: Twenty patients with essential hypertension and fifteen apparently subjects matched for age and weight have been included in this study, Uric acid and total cholesterol were determined by enzymatic methods. High sensitivity C-reactive protein (HsCRP) enzyme immunoassay for the quantitative determination in human serum was used.Results: The data obtained showed that the serum levels of uric acid, CRP and total cholesterol were significantly higher in patients with hypertension than in healthy controls.Conclusion: The conclusion was that hyperuricemia in individuals with essential hypertension is associated with endothelial dysfunction. This association, which is independent of classical risk factors like total cholesterol, CRP, supports the hypothesis that UA plays a significant role in this alteration in humans.

Evaluation of Medical Colleges` Graduates in Iraq

Adnan Al Helli

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 919-925

Background: There are two main medical teaching systems; the older traditional and the newer of block courses methodology. Sequential feedback evaluation of the medical graduates is mandatory in the accredited medical colleges. Most of Iraqi medical colleges apply the traditional UK teaching system. Aims: To evaluate the clinical skills experiences of Iraqi medical college's outcomes and to remind health authority on the resident competency level in order to achieve effective internship training and safe health service. Subjects and methods: During December 2010 a feed back self evaluation was performed for 38 new resident doctors (♀/♂; 26/12), (26) were from University of Karbala, while the rest from other universities. The checklist consisted of 52 randomly closed basic medical skills.Results: Responding rate were (100%).In (16) skills group (34) 94%-(20), 52% respondents claimed having proper performance (median73). In the other 2/, (32) skills3group, (12), 32%-(0), 0% respondents claimed having the skills (median; 22.5). All were untrained to perform 3 life supporting skills. (1♂&8♀) of graduates had the experience to examine the similar sex genitalia. (35; 92%) of graduates were unconfident about their clinical skills. Conclusion: The medical college graduates are under the supposed level of the faculties` objectives. Faculties should implement sequential outcome evaluations, depend the more contemporary integrated teaching methodology aided by the clinical skill labs, and concern the emergency and inpatient training under supervision of expert staff.

Appendicectomy deferred to the next day ;The patient´s opinion

Mohend A.N. Alshalah

Kerbala Journal of Medicine, Volume 3, Issue 7, Pages 926-930

Objective: The aim of this study is to know the opinion of the patients whom had been diagnosed as acute appendicitis and their operations were deferred to the next morning instead of being done at the same night of their admission. Patients and Methods: 102 consecutive patients admitted to the AL Hilla teaching general hospital from the period of Oct/31/2008 to Feb/28/2009 diagnosed as acute appendicitis were admitted from the causality department .Their operations were deferred to the next day for different reasons. Observations overnight were done and then postoperatively a Questionnaire were given to the patients to know their opinion regarding the deferred operation and their overnight complaining.Results: 102 patients were studded, their median age 23 years (10 -58 years); 48 males, 54 females. The majority of these patients (48) were presented between10-12pm.70(68.6 %) patients remembered a reason for deferred operation and the remaining not remembering being given an explanation.66 (64.7 %) of the patients poorly slept preoperatively, mainly due to the pain and ward noise. Operation on the same night as their admission was the preferred option in 82(80.4%) patients. 67(65.6) patients would have preferred the admitting surgeon to perform their operation; 18(17.6%) expressed no preference and 17(16.6%) patients preferred a 'new' surgeon the following day. Of the 102 patients, 13(12.7%) patients did not know who had performed their operation.Conclusion: Most patients would prefer not to have their procedure delayed, In spite of being told why their operation was delayed. Major determinant of patient opinion were lack of sleep pre-operatively. Few patients asked for a 'new' surgeon to perform their operation. There is no system arranges the work in our country for cases of acute appendicitis which presented late at night so we need to improve our surgical practice by" Implementation of a guideline to avoid out-of-hours operation done by a junior doctors'.